General Topics 1

Question 1

According to the Aldrete scoring system, which of the following does NOT support the decision to bypass phase I postanesthesia care unit from the operating room?

Answer 1

A patient’s postoperative nausea and vomiting status is not considered when determining whether they can bypass phase (stage) I postanesthesia care unit (PACU), according to the modified Aldrete scoring system. Instead, it is a criterion for discharge home.

Modified Aldrete Scoring System
Criteria Score and description
Activity 0: Does not move extremities on command
1: Able to move 2 extremities on command
2: Able to move all 4 extremities on command
Breathing 0: Apnea
1: Dyspnea
2: Able to breathe deeply and cough freely
Circulation 0: SBP ± 50 mm Hg of pre-anesthetic level
1: SBP ± 20-50 mm Hg of pre-anesthetic level
2: SBP ± 20 mm Hg of pre-anesthetic level
Consciousness 0: Not responsive
1: Arousable
2: Fully awake
Oxygen saturation* 0: ≤90% despite supplemental oxygen
1: Requires supplemental oxygen to maintain > 90%
2: ≥92% with room air

Question 2

A 63-year-old man is scheduled for laparoscopic cholecystectomy. Which of the following is the MINIMAL amount of time to wait after myocardial infarction in the absence of coronary intervention prior to this elective surgery?

Answer 2

At least 60 days should pass after a myocardial infarction (MI) before noncardiac surgery is performed in the absence of any coronary intervention.
A delay of 14 days is indicated after balloon angioplasty, 30 days after bare-metal stent (BMS) implantation, and 180 days after drug-eluting stent (DES) implantation. The time to wait after DES implantation was updated in 2016.
elective noncardiac surgery, defined as a noncardiac procedure that could be delayed for up to 1 year. Emergency procedures are defined as those that must typically occur within 6 hours. Urgent procedures should be performed in 6 to 24 hours. Time sensitive procedures can wait for 1 to 6 weeks.

Question 3

Which of the following would be excluded from the Health Insurance Portability and Accountability Act Privacy Rule?

Answer 3

The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule does not apply to entities that are either workers’ compensation insurers, workers’ compensation administrative agencies, or employers (except to the extent that they may otherwise be covered entities).

Question 4

Which of the following statements regarding prolonged muscle relaxation by succinylcholine is TRUE?

Answer 4

Both phase 1 and phase 2 blockades of succinylcholine administration display decreased contraction with single twitch stimulus. Phase 1 blockade is associated with fasciculations, minimal fade to TOF (TOF ratio >70%), and enhancement of neuromuscular blockade (NMB) by anticholinesterases. Phase 2 blockade is associated with repeated doses or an infusion of succinylcholine, resembles NDNMB, and can be partially reversed with anticholinesterases. The degree of pseudocholinesterase deficiency is established by the dibucaine number, which is proportional to the amount of normal pseudocholinesterase.

Question 5

When exchanging endotracheal tubes, which of the following is an advantage of using an airway exchange catheter instead of a gum elastic bougie?

Answer 5

Airway exchange catheters have advantages over gum elastic bougies when performing endotracheal tube exchange. These include jet ventilation and end-tidal CO2 monitoring.

Question 6

An 84-year-old man non-smoker with no known cardiopulmonary disease is seen in the preoperative clinic for evaluation prior to revision of total hip replacement. Compared to a healthy 40-year-old man, which of the following statements is MOST LIKELY TRUE for this patient?

Answer 6

Summary of respiratory changes associated with aging:
 Total respiratory system compliance	 Decreased
 Chest wall compliance	 Decreased
 Lung compliance	 Increased
 Lung elasticity	 Decreased
 Muscle mass	 Decreased
 Diaphragm	 Flattened
 Work of breathing	 Increased
 PaO2	 Decreased
 PaCO2	 No Change
 Diffusing capacity	 Decreased
 Alveolar surface area	 Decreased
 V/Q mismatch	 Increased
 Dead space	 Increased
 Tidal volume	 No Change
 Closing capacity	 Increased
 Residual volume	 Increased
 Functional residual capacity	 Increased
 Vital capacity	 Decreased
 FEV1	 Decreased
 Forced vital capacity	 Decreased

Question 7

Which of the following increases lower esophageal sphincter tone?

Answer 7

The majority of anesthetic agents including inhaled agents, opioids, and propofol decrease LES tone and barrier pressure. Succinylcholine, acetylcholinesterase inhibitors, antacids, and some antiemetics increase LES tone. Refer to the table above for a comprehensive list.

TrueLearn Insight : Metoclopramide is relatively contraindicated in patients with Parkinson’s disease due to dopamine (D2)-receptor antagonism.

Question 8

Which of the following is NOT an advantage for having a patient bypass the post-anesthesia care unit (PACU)?

Answer 8

The concept of fast-tracking surgery has taken hold in modern-day anesthetic care for a variety of reasons. As surgical techniques improve, more patients are going to be eligible for this type of care. There are several possible advantages including cost savings, faster time to discharge, and potentially a decreased rate of unplanned hospital admissions. Bypassing the first stage of recovery in the PACU has not been shown to reduce nursing workload.

Question 9

Which of the following is NOT consistent with the definition of monitored anesthesia care (MAC) according to the American Society of Anesthesiologists?

Answer 9

Monitored anesthesia care (MAC) requires the full spectrum of anesthesia physician-directed post-operative care.
MAC involves the use of sedatives, hypnotics, and/or analgesics. MAC requires anesthesia physician supervision with postoperative care and the provider must be qualified and prepared to convert to GA, if necessary. Spontaneous ventilation may be impaired and require intervention for a patent airway.

Question 10

A 45-year-old patient presents for right knee arthroscopy and medial meniscectomy. He has no past medical history and has never had surgery. He is anxious prior to the procedure, and requests something to “take the edge off.” Which of the following is MOST likely TRUE regarding premedication?

Answer 10

Lorazepam premedication can prolong extubation times and does not improve patient satisfaction scores. Clonidine decreases minimum alveolar concentration (MAC) but can increase the risk of hypotension and bradycardia. Fentanyl premedication may actually sensitize patients to pain postoperatively. Scopolamine is more likely than atropine to cause central anticholinergic syndrome.

Question 11

A patient has been receiving subcutaneous unfractionated heparin for 6 days for thromboembolism prophylaxis. The patient is scheduled for hip fracture repair under epidural anesthesia the following morning. Which of the following clinical approaches is MOST appropriate for this patient?

Answer 11

When unfractionated heparin or low–molecular-weight heparin is administered for >4 days, the American Society of Regional Anesthesia and Pain Medicine (ASRA) guidelines recommend checking platelet counts because of the risk of developing heparin-induced thrombocytopenia.

Question 12

Approximately what percentage of anesthesiology residents with substance use disorder in residency will relapse during the course of their career?

Answer 12

At least 40% of anesthesiology residents who were found to have substance use disorder during training relapsed.

Question 13

Laryngeal mask airway use would be MOST appropriate in which of the following patients?

Answer 13

Major contraindications for LMA use include, but are not limited to: patients with a high risk for aspiration of gastric contents, lung disease, airway obstructions, and limited mouth opening.

Question 14

A 67-year-old man is taken to the operating room for an exploratory laparotomy for concerns of bowel ischemia. The anesthesiologist places a brachial arterial line for hemodynamic monitoring. Which of the following statements is the MOST accurate regarding brachial artery catheterization?

Answer 14

Brachial artery catheterization is low risk and can be used for long-term monitoring. Potential complications include thrombosis, infection, and median nerve injury.

TrueLearn Insight : The axillary sheath contains the median, ulnar, and radial nerves. The musculocutaneous nerve is located outside of the axillary sheath.

Question 15

Which of the following is NOT characteristic of hypermagnesemia?

Answer 15

The therapeutic range (for treatment of preeclampsia) for magnesium sulfate therapy is 5-9 mg/dL. Hypermagnesemia does not cause respiratory paralysis until higher serum levels are reached, 15-20 mg/dL.

Hypermagnesemia is typically iatrogenic and symptoms correspond with serum magnesium levels. Reduced deep tendon reflexes are usually seen first and can be followed by cardiac depression and ECG changes, muscle weakness, hypotension, and bradycardia. Respiratory and cardiac arrest occur at very high magnesium levels.

TrueLearn Insight : Magnesium sulfate is administered in preeclamptic patients in order to prevent seizure activity through NMDA antagonism within the CNS.

Question 16

A patient with morbid obesity presents for functional endoscopic sinus surgery. The patient has a Mallampati 3 with a thick tongue and neck circumference of 55 cm. Past medical history includes obstructive sleep apnea, diabetes mellitus, and prior difficult intubation on two occasions. Immediately after induction with propofol and cisatracurium, you are unable to mask ventilate and the SpO2 is 70%. Which of the following is the most reasonable next step?

Answer 16

Airway management in obese patients can be complex and adhering to the ASA difficult airway algorithm is essential. Proper preoperative examination and preparation can help avoid disaster. Difficult airway management generally involves attempts at mask ventilation, supraglottic airway placement, and endotracheal intubation.

Question 17

An intravesical pressure reading of 30 mm Hg is obtained via a urinary catheter. For which of the following is this patient MOST at risk?

Answer 17

Organ System	 Effect 
 Abdominal Wall 	 Decreased compliance
 Decreased rectus sheath blood flow
 Cardiac	 Hypovolemia
 Decreased cardiac output
 Decreased venous return
 Increased central venous pressure
 Increased pulmonary artery occlusion pressure
 Increased systemic vascular resistance
 Central Nervous System	 Decreased cerebral perfusion pressure
 Increased intracranial pressure 
 Gastrointestinal	 Decreased celiac blood flow
 Decreased mucosal blood flow
 Decreased intramucosal pH
 Decreased superior mesenteric artery blood flow 
 Hepatic	 Decreased lactate clearance
 Decreased mitochondrial function
 Decreased portal blood flow 
 Pulmonary	 Decreased dynamic pulmonary compliance
 Decreased PaO2
 Increased dead space ventilation
 Increased intrapulmonary shunt
 Increased intrathoracic pressure
 Increased mean airway pressure
 Increased PaCO2
 Increased peak inspiratory pressure 
 Renal	 Decreased glomerular filtration rate
 Decreased renal blood flow
 Decreased urinary output

Question 18

Which of the following is the MOST common symptom seen with ondansetron at usual clinical doses?

Answer 18

Common side effects of ondansetron include QTc prolongation (20%, very rarely clinically significant), headache (11%), transient AST/ALT increases (5%), constipation (4%), rash (1%), flushing/warmth (< 1%), and dizziness (< 1%).

Question 19

A 17-year-old boy develops pulmonary edema after resolution of postoperative laryngospasm. While breathing 100% oxygen, SpO2 is 80%. Which of the following is the most appropriate initial management?

Answer 19

In instances of pulmonary edema caused by obstruction (e.g. laryngospasm), called negative pressure pulmonary edema or postobstructive pulmonary edema, positive pressure ventilation should be instituted in most cases in order to maintain oxygen saturation.

TrueLearn Insight : Resolution of pulmonary edema after obstructive causes usually occurs in 3 to 12 hours, although complete resolution may take 12 to 48 hours.

Question 20

A 52-year-old male presents with 2nd and 3rd degree burns to 30% of his total body surface area. Which of the following is MOST accurate regarding this patient’s condition?

Answer 20

Large burns can lead to hyperfibrinogenemia which leads to increased platelet aggregation.

TrueLearn Insight : Thromboelastography can be used to assess qualitative fibrinogen function in addition to fibrinogen quantity.

Question 21

Which of the following is a physiologic response of acetylcholine binding to the muscarinic receptor?

Answer 21

The muscarinic receptors are found at the peripheral target organs. Stimulation will cause bradycardia, bronchoconstriction, miosis, salivation, gastrointestinal hypermotility and increased gastric acid secretion.

Question 22

Which of the following is TRUE regarding intravenous anesthetics and thrombophlebitis?

Answer 22

Intravenous administration of etomidate is associated with pain on injection, postoperative nausea and vomiting, and superficial thrombophlebitis. Ways to prevent thrombophlebitis are to use larger veins, increasing the speed of injection, and pretreatment with lidocaine. Treatment options are controversial but include the use of NSAIDS and elastic stockings.

Question 23

Which of the following BEST approximates the FiO2 provided by a simple face mask with oxygen flows of 5-10 L/min?

Answer 23

Nasal cannulas provide an FiO2 of 25-40% with flow rates up to 6 L/min. Simple face masks supply 35-50% FiO2 with flow rates >5 L/min. A partial rebreathing mask is a simple face mask with a reservoir bag that enhances FiO2 to 40-70% with oxygen flows of >6 L/min.

Question 24

Which of the following scenarios, in a patient with an endotracheal tube 1 cm above the tracheal carina, is MOST likely to result in accidental advancement of the endotracheal tube into the bronchus?

Answer 24

Unintentional endobronchial intubation typically occurs within the right bronchus. Common intraoperative situations that can lead to inadvertent advancement of the endotracheal tube into the bronchus are pneumoperitoneum, head and neck flexion, and Trendelenburg position.

TrueLearn Insight : When determining how the endotracheal tube (ETT) moves with respect to neck flexion or extension, providers remember that “the ETT tip follows the chin.” Neck flexion points the chin down and pushes the ETT down/in. Neck extension points the chin up and pulls the ETT up/out. An alternative mnemonic is “Hose follows the nose.”

Question 25

Which of the following is NOT included in the modified Aldrete scoring system used to assess readiness for discharge from the post-anesthesia care unit (PACU)?

Answer 25

The modified Aldrete scoring system is used to assess patients for readiness for discharge from Phase I of PACU. The score looks at activity, respiration, circulation, consciousness, and oxygen saturation.

Question 26

A large-volume administration of which of the following intravenous fluids will result in a decreased serum osmolality?

Answer 26

Plasma osmolality is a measure of the body’s electrolyte-water balance. Many solutions are considered isotonic although they may be physiologically hypertonic or hypotonic to plasma. Infusion of lactated Ringer solution will decrease serum osmolality.

TrueLearn Insight : When lactated Ringer solution is administered to a healthy patient, the lactate is metabolized by the liver to bicarbonate. Due to this reliance on hepatic metabolism of infused lactate, lactated solutions should be avoided in severe liver failure.

Question 27

A 28-year-old woman requires an urgent appendectomy during her third trimester of pregnancy. Preoperatively, she receives 15 mL of non-particulate antacid, 50 mg of ranitidine, and 25 mg of metoclopramide. The patient complains of severe nausea in the PACU following the procedure and receives 4 mg of ondansetron and 5 mg of prochlorperazine. Shortly thereafter, the patient reports feeling restless and begins exhibiting irregular movements of her arms and legs. Which of the following classes of drugs will MOST likely treat her symptoms?

Answer 27

Antidopaminergic drugs can cause extrapyramidal symptoms (EPS), particularly when used chronically, in high doses, or when multiple drugs from the class are used simultaneously. Anticholinergics are considered first-line therapy for EPS.

TrueLearn Insight : Diphenhydramine has antihistamine (H1) and anticholinergic activity, inhibits serotonin reuptake, potentiates opioid-induced analgesia, and may have local anesthetic-like properties (intracellular sodium channel blocker).

Question 28

Which of the following is responsible for the efferent limb of the laryngospasm reflex?

Answer 28

The internal branch supplies all sensation to the mucosa above the vocal folds. The external branch supplies the motor innervation to the cricothyroid muscle. The recurrent laryngeal nerve supplies sensory innervation below the vocal cords as well as all motor innervation to the laryngeal muscles except the cricothyroid muscle.

The efferent branch of the laryngospasm reflex is mediated by the recurrent laryngeal nerve (RLN) and the external branch of the superior laryngeal nerve (SLN). For the laryngospasm response, the RLN innervates the lateral cricoarytenoid, and transverse arytenoid, and the external branch of the SLN innervates the cricothyroid muscles.

Question 29

Which of the following statements about hydroxyethyl starches is INCORRECT?

Answer 29

Hydroxyethyl starches are synthetic colloids useful for volume resuscitation due to prolonged intravascular half-lives. Hetastarches are traditionally associated with a higher risk of coagulopathies (platelet adhesion interference, reduced factor VIII:C and vWF levels, and PTT prolongation) than the newer, lower molecular weight tetrastarches.

Question 30

Which of the following is MOST TRUE about the substance abuse disorder (SUD) in anesthesia providers?

Answer 30

Risk factors for substance abuse include access to substances of abuse, personal history of drug abuse, family history of drug abuse, psychiatric disease, male sex, and completing medical education in the United States.

TrueLearn Insight : The Opioid Risk Tool (ORT) is used in chronic pain management to assess a patient’s risk for abuse when starting opioid medications. Risk factors include family history of substance abuse (alcohol, illegal drugs, prescription drugs), personal history of substance abuse (alcohol, illegal drugs, prescription drugs), age 16-45, history of preadolescent sexual abuse, and psychologic disease (ADD, OCD, bipolar, schizophrenia, depression).

Question 31

A 45-year-old ASA PS 1 patient is brought to the operating room for laparoscopic appendectomy. Initial vitals signs are suggestive of sepsis including an elevated core temperature. After induction of general anesthesia, a significant drop in esophageal temperature is noted. Which of the following BEST explains this physiologic change?

Answer 31

The initial reduction in core temperature in patients under general anesthesia is the redistribution of heat from the core to the periphery.

Question 32

A 51-year-old man is undergoing implantation of a temporary spinal cord stimulator. An anesthesiologist is present and delivering monitored anesthesia care (MAC). Ten minutes into the procedure he is not responding to any verbal command or light touch but does make purposeful movements after a painful attempt to create a pocket in his tissue. What is his depth of sedation?

Answer 32

With deep sedation and analgesia, a patient will not be aroused by verbal command or light tactile stimulation. However, with repeated or painful stimuli, they will make purposeful movements. In addition, under deep sedation-analgesia intervention may be required to maintain a patent airway, spontaneous ventilation may be inadequate, but hemodynamic stability is usually maintained.

Question 33

A paresthesia over which of the following areas is LEAST likely to result from use of the lithotomy position?

Answer 33

The lithotomy position is commonly used for gynecologic and urologic procedures and involves flexion of the hips and knees. Maintenance of the lithotomy position for prolonged periods of time can result in a stretch injury to the sciatic nerve and compression injuries to nerves that pass beneath and through the inguinal ligament, including the obturator and lateral femoral cutaneous nerves.

Question 34

Which of the following necessitates a minimum fasting period of 6 hours prior to induction of general anesthesia for elective surgery in an otherwise healthy patient?

Answer 34

The “2-4-6-8 rule” for NPO guidelines are recommendations which apply to healthy non-parturient patients undergoing elective surgery. Both the amount and type of liquid and food ingested should be considered when determining an appropriate fasting period

Question 35

Which of the following patients would benefit MOST from an intravenous anesthetic induction using ketamine?

Answer 35

Ketamine increases HR, BP, CO, CBF, ICP, CMRO2, IOP, salivation, and lacrimation. It preserves respiratory drive, airway reflexes, and acts as a bronchial smooth muscle relaxant. Asthmatic patients can greatly benefit from intravenous ketamine unless contraindications are present (e.g., coronary artery disease (CAD), open globe, increased ICP from intracranial tumor or hemorrhage).

Question 36

An 82-year-old male with metastatic esophageal cancer treated with chemotherapy is scheduled for a feeding gastrostomy tube placement under general anesthesia. He has a do-not-resuscitate order and is deferring all medical decisions to his wife who has legal power of attorney. Which of the following is the BEST way to proceed with the procedure and anesthesia?

Answer 36

Prior to surgery and anesthesia in any patient with advanced directives or orders that limit treatment, a discussion should be held with the patient, family members, and/or legal representative to determine which interventions and resuscitation options are acceptable perioperatively and for how long any changes made should apply postoperatively.

Question 37

End tidal carbon dioxide suddenly drops to near zero intraoperatively. Which of the following is NOT a potential associated finding?

Answer 37

Causes of a sudden drop in ETCO2 include but are not limited to cardiovascular collapse, massive VAE, large PE, esophageal intubation, circuit or sampling line disconnection, or a dislodged/kinked endotracheal tube.

Question 38

Which of the following is typically seen with a phase I neuromuscular block?

Answer 38

Standard intubating doses of succinylcholine generally create a phase I depolarizing block characterized by decreased twitch height, sustained tetanus, and a train-of-four ratio >0.7. Neostigmine will potentiate a phase I block, while a nondepolarizing neuromuscular blocking drug (NMBD) will antagonize the block. Prolonged infusions or large doses of succinylcholine create a phase II nondepolarizing block, which is similar to that created by nondepolarizing NMBDs.

TrueLearn Insight : Standard intubating doses of succinylcholine may create a phase II block in patients with pseudocholinesterase deficiency. The increased duration of action results in “succinylcholine apnea” that can last up to several hours.

Question 39

A 72-year-old male has just undergone a laparoscopic colectomy under general anesthesia. During abdominal insufflation, he has a bradycardic episode that does not resolve with removal of surgical stimulation. Glycopyrrolate is given with good effect. In the post-operative recovery area, he has some symptoms related to this medication. Which of these is NOT an adverse effect of glycopyrrolate?

Answer 39

Glycopyrrolate is an anticholinergic medication that more specifically blocks the muscarinic receptors of the parasympathetic nervous system. This leads to a blockage of many parasympathetic responses including GI motility, salivation, and urination.

TrueLearn Insight : The mnemonic SLUDGE-Mi can be used remember cholinergic symptoms, such as those seen with acetylcholinesterase inhibitors, organophosphate poisoning, and nerve agents. The opposite symptoms are therefore seen with the use of anticholinergic medications. SLUDGE-Mi: Salivation, Lacrimation, Urination, Defecation, Gastrointestinal upset, Emesis, Miosis. Saying the mnemonic as “Sludge Me” helps differentiate miosis and mydriasis.

Question 40

A 44-year-old female is undergoing endometrial ablation in the lithotomy position while under general anesthesia with a laryngeal mask airway. Halfway through the case, bilious fluid is observed in the airway tube and the patient’s SpO2 drops to the low 90s. Which of the following steps is MOST appropriate to take at this time?

Answer 40

Initial steps for management of suspected or confirmed pulmonary aspiration of gastric contents in patients with a LMA include increasing FiO2 to 100%, deepening anesthesia, and placing the patient in a head-down position. Suctioning should usually be performed and the severity of aspiration assessed using fiberoptic bronchoscopy. Additional measures such as intubating should be based on clinical judgment.

Question 41

Which of the following will DECREASE the alveolar partial pressure of oxygen?

Answer 41

The alveolar gas equation is used to determine alveolar oxygen tension. PAO2 = [(Patm – PH2O) * FiO2] – (PACO2 / R). Increases in Patm and FiO2 and decreases in PH2O and PACO2 lead to increases in PAO2.

TrueLearn Insight : By comparing the PAO2 and the PaO2 (A-a gradient and A:a ratio), a determination of oxygenation can be made. A normal A-a gradient is < 10 mm Hg, and a normal a-A ratio is >0.75.

Question 42

An anesthesiologist is performing an experiment in the laboratory to determine resistance to flow at high flow rates. Which of the following gas mixtures has the LEAST resistance through a small diameter endotracheal tube at high flows?

Answer 42

Helium has an extremely low density and thus has an increased tendency for laminar flow. Helium reduces airway resistance in large and medium airways (reduced resistance in turbulent flow). It can be used to decrease the work of breathing in pathologic conditions.

Question 43

Which of the following statements regarding substance abuse among anesthesiologists is TRUE?

Answer 43

Common characteristics shared by substance abusing anesthesiologists include: half are < 35 years old, high incidence of polysubstance abuse, opioids as the drug class of choice, and a higher prevalence noted in academic environments.

Question 44

A 35-year-old previously healthy male is brought into the trauma bay after a motor vehicle crash. He has minimal traumatic injuries but a Glasgow Coma Scale score of 3. Imaging reveals a massive hemorrhagic stroke that is not compatible with survival. The patient is brought to the intensive care unit and is declared brain dead. During preparation for multi-organ donation, the patient begins to decline hemodynamically and is brought urgently to the operating room for procurement. Which of the following is the most appropriate American Society of Anesthesiologists (ASA) physical status classification for this patient?

Answer 44

The ASA physical status classification is not intended for use as a measure to predict operative risk but to assess the degree of patients’ comorbidities and overall physical state prior to surgery. ASA PS 6 represents a patient who has been declared brain-dead and whose organs are being harvested for donation. The GCS score is the most widely used scoring system for the quantifying level of consciousness following TBI. The lowest score is a 3 and the best score is 15.

Question 45

A patient is 2 hours post-open reduction internal fixation of a distal radius fracture following a traumatic injury when the recovery room nurse pages the surgeon to evaluate the patient’s cool, tense arm. The patient had an infraclavicular single-shot block 1 hour before induction with general anesthesia for the surgery. The patient is still sleepy due to the general anesthetic and several recovery room doses of morphine for severe lower back pain. Which of the following is the BEST step for diagnosis of this patient’s condition?

Answer 45

Prompt diagnosis of a patient with suspected compartment syndrome is absolutely essential for optimal outcome. Diagnosis is made based on clinical symptoms and then via direct compartment pressure measurement. This is still debated, and no randomized controlled trials have shown that regional anesthesia is contraindicated when concerned about acute compartment syndrome.

Question 46

You are caring for an 87-year-old male who is scheduled to undergo an elective hernia repair. The patient has a clear medical directive that specifically states no cardiopulmonary resuscitation (DNR order). The patient wants the anesthesia and surgical staff to abide by this wish intra-operatively. Which of the following is the best way to proceed?

Answer 46

Do not resuscitate orders in the perioperative period must be carefully discussed and documented with the patient’s true wishes. It is important to discuss with the patient that many causes of cardiac arrest in the perioperative period are reversible and/or easily treated.

Question 47

Following induction of anesthesia with propofol, lidocaine, and rocuronium, a 17-year-old patient is noted to have elevated peak airway pressures and bilateral diffuse wheezing. Blood pressure is 72/30 mm Hg. Which of the following is the BEST initial treatment?

Answer 47

Epinephrine is the first-line treatment in the setting of IgE-mediated anaphylaxis as it stimulates alpha and beta receptors causing increase in SVR, cardiac output, and bronchodilation. It is also a mast cell stabilizer and therefore reduces systemic histamine and thromboxane levels.

TrueLearn Insight : Acute coronary events associated with hypersensitivity reactions are referred to as “Kounis syndrome,” or allergic angina or allergic myocardial infarction. Paradoxical bradycardia may occur during severe acute hypovolemia during anaphylaxis. This is a result of the Bezold-Jarisch reflex, a cardioinhibitory reflex initiated by stretch receptors in the left ventricle and transmitted by vagal fibers.

Question 48

Which of the following is NOT a component of the treatment of laryngospasm?

Answer 48

Initial treatment of laryngospasm includes administration of 100% oxygen, CPAP, removal of any offending foreign bodies or secretions, and increasing the depth of anesthesia. Succinylcholine may be used as a last resort and with caution in pediatric patients due to bradycardia and the risk of triggering MH.

Question 49

A 34-year-old female is taken to the operating room for laparoscopic cholecystectomy. She is 5’4” tall and weighs 113 kg. She has a history of post-operative nausea and smokes one pack of cigarettes a day.
Which of the following does NOT increase the risk for postoperative nausea and vomiting?

Answer 49

PONV Risk factors in adults 
Age < 50 years old
 Female gender
 History of PONV or motion sickness
 Non-smoker

Question 50

The patient receives intravenous dexamethasone 4 mg and ondansetron 4mg intraoperatively for nausea prophylaxis. However, post-operatively the patient complains of nausea. Which of the following is the recommended management for this patient?

Answer 50

1) 5-HT3 receptor antagonist (e.g., ondansetron): commonly used in the perioperative management of PONV. Better at preventing vomiting than nausea. The recommended dose for ondansetron is 4mg at the end of the surgery. Do not re-dose unless more than 6 hours have elapsed since the last dose was administered, including in the immediate post-operative period. An adverse effect is QTc prolongation.
2) NK-1 receptor antagonist (e.g., aprepitant): more effective than ondansetron. Recommended to give prior to the start of surgery.
3) Corticosteroids (e.g., dexamethasone): recommended dosing is 4 mg at the beginning of the surgery due to long onset time.
4) Dopamine-2 receptor antagonist (e.g., droperidol, metoclopramide): droperidol is effective as an anti-emetic. Recommended dosing is 0.625 to 1.25 mg at the end of surgery. Metoclopramide is considered a weak anti-emetic. The effective dose for metoclopramide is 25 to 50 mg. Metoclopramide 10mg is not recommended for PONV. Also, metoclopramide is not recommended as an antiemetic for patients who have received prophylactic ondansetron intraoperatively.
5) Anti-cholinergics (e.g. scopolamine patch): need to apply prior to going back to the operating room due to its 2 to 4 hour onset time. Can cause visual changes, dry mouth, and dizziness.